Gokoulakrichenane Loganadane1, Jacqueline R Kelly2, Nicholas C Lee3, Benjamin H Kann2, Amit Mahajan4, James E Hansen2, Yazid Belkacémi5, Wendell Yarbrough6, Zain A Husain2. 1. Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut; APHP, University of Paris-Est Créteil, Department of Radiation Oncology, Créteil, France. 2. Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut. 3. Yale School of Medicine, New Haven, Connecticut. 4. Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut. 5. APHP, University of Paris-Est Créteil, Department of Radiation Oncology, Créteil, France. 6. Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
Abstract
PURPOSE: Initial deescalation studies for human papilloma virus (HPV)-positive driven oropharyngeal squamous cell carcinomas (HPV+ OPSCC) altered radiation therapy dose or the systemic agent used. Newer trials examine the disease control achieved with a reduced elective nodal field. We examined patterns of nodal involvement in patients with HPV+ OPSCC with a focus on implications for radiation field design for treatment deescalation. METHODS AND MATERIALS: Records of patients with HPV+ OPSCC with preoperative imaging (computed tomography or fludeoxyglucose positron emission tomography/computed tomography) who underwent neck dissection without neoadjuvant therapy from 2010 to 2017 were retrospectively reviewed. The number and location of clinically positive lymph nodes on preoperative imaging were compared with those documented on pathology. These data were then used to establish the probability of missing nodal disease in 3 modified radiation field designs. RESULTS: One hundred patients were included. The median time between imaging and surgery was 22 days. The most common clinical N stage was cN2a (35%), whereas the most common pathologic N stage was pN2b (45%). The median number of radiographically and pathologically involved nodes was 1 (range, 0-6) and 2 (range, 0-11), respectively. Forty-three percent of patients had more pathologically involved nodes than predicted on imaging, whereas 21% had pathologic involvement at an additional nodal level not predicted on imaging. Of the 21 patients with additional pathologically involved nodal levels, 14 had involvement of a directly adjacent station, 4 were patients with a cN0 hemineck with pathologically positive level II disease, and 3 had pathologic involvement of level 2 echelons removed from that predicted on imaging. CONCLUSION: Our study suggests that radiation fields encompassing only clinically involved nodes or levels has an unacceptably high likelihood of missing subclinical disease. Alternatively, treating the first uninvolved echelon nodes in addition would cover pathologic sites of disease in 97% of patients. This approach merits further study in prospective trials.
PURPOSE: Initial deescalation studies for human papilloma virus (HPV)-positive driven oropharyngeal squamous cell carcinomas (HPV+ OPSCC) altered radiation therapy dose or the systemic agent used. Newer trials examine the disease control achieved with a reduced elective nodal field. We examined patterns of nodal involvement in patients with HPV+ OPSCC with a focus on implications for radiation field design for treatment deescalation. METHODS AND MATERIALS: Records of patients with HPV+ OPSCC with preoperative imaging (computed tomography or fludeoxyglucose positron emission tomography/computed tomography) who underwent neck dissection without neoadjuvant therapy from 2010 to 2017 were retrospectively reviewed. The number and location of clinically positive lymph nodes on preoperative imaging were compared with those documented on pathology. These data were then used to establish the probability of missing nodal disease in 3 modified radiation field designs. RESULTS: One hundred patients were included. The median time between imaging and surgery was 22 days. The most common clinical N stage was cN2a (35%), whereas the most common pathologic N stage was pN2b (45%). The median number of radiographically and pathologically involved nodes was 1 (range, 0-6) and 2 (range, 0-11), respectively. Forty-three percent of patients had more pathologically involved nodes than predicted on imaging, whereas 21% had pathologic involvement at an additional nodal level not predicted on imaging. Of the 21 patients with additional pathologically involved nodal levels, 14 had involvement of a directly adjacent station, 4 were patients with a cN0 hemineck with pathologically positive level II disease, and 3 had pathologic involvement of level 2 echelons removed from that predicted on imaging. CONCLUSION: Our study suggests that radiation fields encompassing only clinically involved nodes or levels has an unacceptably high likelihood of missing subclinical disease. Alternatively, treating the first uninvolved echelon nodes in addition would cover pathologic sites of disease in 97% of patients. This approach merits further study in prospective trials.
Authors: Aisling S Last; Patrik Pipkorn; Stephanie Chen; Dorina Kallogjeri; Joseph Zenga; Jason T Rich; Randal Paniello; Jose Zevallos; Rebecca Chernock; Douglas Adkins; Peter Oppelt; Hiram Gay; Mackenzie Daly; Wade Thorstad; Ryan S Jackson Journal: JAMA Otolaryngol Head Neck Surg Date: 2020-01-01 Impact factor: 6.223
Authors: Rustain L Morgan; Megan M Eguchi; Adam C Mueller; Stacie L Daugherty; Arya Amini; Sana D Karam Journal: Cancer Date: 2019-05-01 Impact factor: 6.860